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Preventing cancer has much to offer. Aside from plummeting health care costs, we might enjoy a healthier life free of cancer and chronic disease. Prevention requires the adoption of healthier choices and a moderate amount of exercise. The supporting evidence is observational, clinical, and partly common sense. Further investigations reveal several substances in a whole-food plant-based diet that have protective effects and an inhibitory effect on tumor development. For pancreatic cancer, the basis of cure remains a century old operation that rarely cures. With little to lose, prevention deserves center stage and additional studies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Preoperative drainage of an obstructed biliary tree before pancreaticoduodenal resection (PDR) and placement of intraabdominal drains following pancreatic resection have been suggested to be both unnecessary and associated with a higher complication rate. The evidence for and against that practice is presented and analyzed to highlight its risks and benefits. A selective approach on an individual basis for preoperative biliary decompression is advocated, based on multiple factors. Additionally, the evidence for routine use of surgical drains after PDR is critically reviewed and the rationale for routine drainage is made., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Complications after pancreaticoduodenal resection occur in at least 30% of patients. Most are a direct result of an intraoperative event, dissection, or anastomoses which account for the most serious morbidities, sepsis, pseudoaneurysms, and hemorrhage. Rarely, complications are due to the systemic impact of the procedure even if the procedure itself was unremarkable. Rare systemic complications after PDR (Transfusion transmitted Babesiosis, pituitary apoplexy, and TRALI) and a number of uncommon and unusual other complications are discussed. Pancreaticoduodenal resection is a significant operation with serious consequences. Decisions on selection of candidates and safe operations should be thoughtful and always in surgeons' minds., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Asymptomatic non-functioning pancreatic neuroendocrine tumors are indolent, slow-growing tumors, and surveillance is safe and reasonable. Despite consensus, size may be less important than grade and Ki-67 when making decisions regarding optimal therapy. Plans to proceed with surveillance or surgical resection require a multidisciplinary approach and a shared decision making process with colleagues, patients, and families. Decisions should be based on tumor characteristics, patient morbidities, preferences, and risks. As molecular diagnostics evolve, preoperative acquisition of tissue samples may become even more critical in choosing between operative management and surveillance., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The incidence of cancer in choledochal cysts (CCs) in adults was calculated to determine the timing and need for surgery. In 78 publications (1996-2010), 434 of 5780 reported CCs patients had cancer. Cholangiocarcinoma (70.4 %) and gallbladder cancer (23.5 %) were the most common malignancies. Only nine malignancies were reported before age 18 (0.42 %). In contrast, the incidence of malignancy in adults was 11.4 %. The median age for diagnosis of cancer was 42 years, and the incidence increased with each decade.

Three sporadic, synchronous, and separate lesions in the ampulla of Vater and the head of the pancreas presented in an 81-year-old male. One was symptomatic and two were incidental. One was detected preoperatively (the ampullary lesion) and two by examination of the resected specimen (the neuroendocrine and pancreatic carcinomas). The case is summarized and the literature and the issue of commonality are reviewed.

At-risk family members with familial pancreatic cancer (FCaP) face uncertainty regarding the individual risk of developing pancreatic cancer (CaP) and whether to choose serial screening or prophylactic pancreatectomy to avoid CaP. We treated 2 at-risk siblings with a history of FCaP, congenital hepatic fibrosis (CHF), and jaundice secondary to a bile duct stricture. In one, a pancreaticoduodenal resection was done and in the second a total pancreatectomy. Malignancy was not present, but extensive pancreatic intraepithelial neoplasia (PanIn) 2 was present throughout both pancreata. The clinical course and literature review are presented along with the previously unreported association of CHF and CaP.

Molecular-based methods to monitor point mutations require special and expensive equipment unavailable in most hospitals. Colorimetric-based analysis is an ideal platform for K-ras codon 12 gene point mutations because it uses commonly found hospital equipment. The colorimetric assay is sensitive and specific, detecting mutated DNA levels as low as 1% in a wild-type background. Paired genomic DNA extracts of fixed tissue and cellular fractions of peripheral blood are more sensitive and accurate than unpaired samplings. This approach has the potential to improve K-ras point mutation scans as well as to detect micrometastases in circulating tumor cells.

Background: Central pancreatectomy has a unique application for lesions in the neck of the pancreas. It preserves the distal pancreas and its endocrine functions. It also preserves the spleen., Methods: This is a retrospective review of 10 patients who underwent central pancreatectomy without pancreatico-enteric anastomosis between October 2005 and May 2009. The surgical indications, operative outcomes, and pathologic findings were analyzed., Results: All 10 lesions were in the neck of the pancreas and included: 2 branch intraductal papillary mucinous neoplasms (IPMNs), a mucinous cyst, a lymphoid cyst, 5 neuroendocrine tumors, and a clear cell adenoma., Conclusion: Central pancreatectomy without pancreatico-enteric anastomosis for lesions in the neck and proximal pancreas is a safe and effective procedure. Morbidity is low because there is no anastomosis. Long term endocrine and exocrine function has been maintained.

Background: Pancreaticoduodenectomy is the procedure of choice for tumors of the head of the pancreas and periampulla. Despite advances in surgical technique and postoperative care, the procedure continues to carry a high morbidity rate. One of the most common morbidities is delayed gastric emptying with rates of 15%-40%. Following two prolonged cases of delayed gastric emptying, we altered our reconstruction to avoid this complication altogether. Subsequently, our patients underwent a classic pancreaticoduodenectomy with an undivided Roux-en-Y technique for reconstruction., Methods: We reviewed the charts of our last 13 Whipple procedures evaluating them for complications, specifically delayed gastric emptying. We compared the outcomes of those patients to a control group of 15 patients who underwent the Whipple procedure with standard reconstruction., Results: No instances of delayed gastric emptying occurred in patients who underwent an undivided Roux-en-Y technique for reconstruction. There was 1 wound infection (8%), 1 instance of pneumonia (8%), and 1 instance of bleeding from the gastrojejunal staple line (8%). There was no operative mortality., Conclusion: Use of the undivided Roux-en-Y technique for reconstruction following the Whipple procedure may decrease the incidence of delayed gastric emptying. In addition, it has the added benefit of eliminating bile reflux gastritis. Future randomized control trials are recommended to further evaluate the efficacy of the procedure.

Pancreatic cancer is a systemic disease for most patients. Operations with the intent to cure may be done safely (mortality, < 3%) with shorter hospital stays. Surgery has been minimally effective as a long-term cure. Endoscopic palliation of jaundice is becoming standard practice. Common sense dictates a defined and clear role for surgery (i.e., strict patient selection criteria). Surgery is of great value for small, localized lesions; of clear value as palliative therapy when nonoperative measures fail; and perhaps best applied after neoadjuvant chemoradiotherapy. Surgery is just part of the armamentarium available to treat pancreatic cancer. Novel systemic therapies, including chemotherapy, immunotherapy, and so-called targeted therapies, are becoming increasingly valuable in the management of this systemic disease and are discussed in detail in other articles in this issue.

Pancreatic and biliary fistulas and delayed gastric emptying are the most common complications after pancreatoduodenectomy. The development and bleeding of visceral arterial pseudoaneurysms are rare phenomena and pose diagnostic and treatment dilemmas. We describe 5 recent patients who developed bleeding from visceral artery pseudoaneurysms after pancreatoduodenectomy. These patients all had "herald" bleeding from their abdominal drains. Subsequent angiography and therapeutic embolizations were successfully performed.

Long-term follow-up of 5 or more years in 20 patients with initially unresectable cancer of the pancreas that responded to chemoradiation therapy is detailed in this article. All patients underwent resection. Seven or 18 surgical survivors are alive 50 or more months.

Despite accurate diagnosis, better radiologic techniques, and safer surgery, long-term survival after surgical therapy for pancreatic cancer is disappointing. Median survival following pancreaticoduodenal resection is 12 to 15 months independent of surgical expertise, hospital size, or technical factors. Subsets of favorable tumors and longer survival times after surgery have been defined and include: small tumor size and low-grade lesions, tumor-free margins, and absence of nodal, venous, or perineural invasion; however, long-term survivors of pancreatic cancer may have none of these favorable features, and their tumors commonly manifest the most adverse tumor prognostic features. The converse that small-sized, histologically favorable tumors result in long-term survivors, also is not true. Five-year survival rates average 5% or less after all resections. In a large series in which 118 pancreatic resections were performed in 684 evaluated patients over a 6-year period, there were 12 5-year survivors, 5 of whom died in the sixth year. A report of 10-year survivors after surgery numbered 13 patients. The best actual 5-year survival rate was reported by Trede et al. Of the 37, 5-year survivors from a cohort of 118 patients, more than half died of cancer. This far exceeds any other actual survival rate and may be explained by a smaller tumor size. Farnell et al reported a 5-year survival rate difference (i.e., actuarial survival) in a subset of 174 resected patients with adenocarcinoma without perineural or duodenal invasion and with negative nodes (23% versus 6.8%), respectively. An impressive, large series of 616 patients with resected adenocarcinoma of the pancreas who underwent PDR (85%), distal pancreatectomy (9%), and total pancreatectomy (6%), has been reported. The mortality rate was 2.1%, and postoperative complications occurred in 30%. The five-year survival rate was 15%. The author's best result was observed among 20 initially "unresectable" patients who were treated with chemoradiation therapy, followed by tumor extirpation. Among the 18 surgical survivors there are seven five-year survivors, three of whom are in their tenth year of survival. They are discussed in the article by Cooperman et al ("Long-term Follow-up...") elsewhere in this issue.

The diminished role of surgery and increased role of nonoperative interventional therapy for pancreatic pseudocysts is discussed. The natural history supports prolonged observation for most asymptomatic pseudocysts.

The surgical treatment of pancreatic pseudocysts (PC) has a less important role now that endoscopic and radiologic intervention can effectively treat PC. Surgery may be needed to correct the underlying cause--usually an obstructed or disrupted pancreatic duct.

CT has evolved over 24 years as an effective cross-sectional imaging modality for benign and malignant pancreatic diseases. Multiphase helical scanners with rapid infusion of intravenous contrast medium allow for the delineation of pancreatic parenchymal, arterial, and venous studies with identification of malignant and benign lesions. Therapeutic applications abound, and CT drainage of postoperative fluid collections, pseudocysts, and abscesses will have an increasing role in the new millennium.

Pancreas divisum has generated varying enthusiasm regarding operative intervention. Applying similar principles to divisum surgery as for the surgical treatment of chronic pancreatitis will yield a better outcome than using subjective symptoms.

It is hoped that, in this millennium, chronic pancreatitis will be diagnosed earlier in the course of the disease process. Improved axial imaging of the pancreatic duct and pancreatic parenchyma will diminish the need for other invasive tests. Surgical procedures are directed at pancreatic duct decompression or resection of the pancreas (head, body or tail) or, infrequently, total pancreatectomy. Pain relief in 75% to 90% is the general rule, with diabetes developing subsequently in as many as 33% of patients. Surgery for chronic pancreatitis is effective in correcting sequelae of pancreatic fibrosis. Endoscopic stenting of the pancreatic and bile duct is used more frequently today. Until their place is ascertained, careful performance of surgery will continue to be a mainstay of treatment.

Despite progress in treating many solid tumors, pancreatic cancer continues to be a grave illness. Each year, >29,000 new cases of adenocarcinoma of the pancreas are diagnosed in the United States. Of these patients, only 10-20% have resectable tumors and 25,000 patients (83%) die within 12 months of diagnosis. Until recently, surgery has been the only "effective" therapy available for select patients. Historically, the operative mortality after radical pancreatic resection has been variable, ranging 1-30%, and is both operator- and institution-dependent. Even with a safe and complete surgical resection, the actual 5-year survival after surgery alone is essentially zero, although rates up to 5% have been reported. Despite what would appear to be a dismal outlook, slow progress has occurred in the operative and postoperative care of patients with pancreatic cancer. Advanced imaging techniques and laparoscopy have limited the number of unnecessary laparotomies, and novel adjuvant and neoadjuvant chemotherapy approaches have yielded promising results. This review will summarize the recent literature concerning the surgical therapy and trends in the treatment of carcinoma of the pancreas from 1990 to 1999.

Most patients with pancreatic cancer suffer from a variety of severe metabolic and nutritional disturbances. Despite this fact, the role of perioperative nutritional support for these patients remains controversial. This review highlights the results of randomized prospective clinical trials, and meta-analyses that have addressed this issue. The 'current opinion' put forth in this discussion is based on these reviews, and on personal observations in treating more than 500 patients.

Objective: To determine whether pancreaticoduodenal resection (PDR) for benign and malignant disease can be performed safely, efficiently, and economically at a 50-bed community hospital., Design: Retrospective review of 39 consecutive PDRs performed in an 18-month period. Indications for surgery, length of hospital stay, complications, and patient charges were analyzed., Setting: A suburban 50-bed community hospital., Patients: Thirty-nine patients (15 male and 24 female) referred for PDR for benign and malignant disease., Main Outcome Measures: Mortality and morbidity rates, length of hospital stay, care, and cost., Results: Of 39 patients who underwent PDRs, 1 patient (2.6%) died of myocardial infarct. Intraoperative blood transfusions were required by 3 patients (8%). The mean postoperative hospital stay was 11 days. Twenty-four patients (62%) were discharged by day 11. Fifteen patients (38%) were hospitalized 11 to 24 days. Complications in 10 patients (28%) included pancreatic or biliary fistula (n = 6), upper gastrointestinal tract bleeding (n = 1), partial wound dehiscence (n = 1), bacteremia (n = 1), and pneumonia (n = 1). No patient required reoperation. Three patients were rehospitalized within 1 month. Mean patient charges were $21,864, and mean reimbursements were $19,669., Conclusions: Pancreaticoduodenal resection can be accomplished with low morbidity and mortality rates and a short stay at a community hospital. Thorough preoperative investigations to exclude unresectable lesions must precede every PDR for malignant disease. Mortality and morbidity rates in this series were similar to those for patients with similar diagnoses who were operated on in academic centers. Cost for and length of hospital stay of these 39 patients were significantly lower than those in other reported series.

Objective: To assess the outcome of endoscopic techniques as the solitary treatment modality for the complete management of ascending, bacterial cholangitis, compared with results of radiological and surgical methods as historical controls., Methods: Endoscopic techniques were used to decompress bile ducts obstructed by stones (898 patients) or stenosis (49 patients). Endoscopic sphincterotomy (ES) was performed in 839 patients, and either 7-Fr straight stents (79), or nasobiliary tubes (29), were utilized as initial therapy in 108 patients. Of these latter patients, 68 subsequently underwent ES and stone removal, 17 had ES, lithotripsy, and stone removal, 18 were left with stents in place, and 5 were lost to follow-up. Follow-up was conducted by direct patient contact, by telephone, or through the referring physicians., Results: All patients were managed by endoscopic techniques. There were four deaths (0.42%) in the first 30 days (none before 2 wk); no deaths were related to the procedures but were attributed to intercurrent medical problems. Two patients underwent surgery: one pancreatitis, one perforation. Complications were infrequent, occurring in 6% of patients. Bleeding occurred in 3%, pancreatitis in 2.8%, and perforation 0.2%., Conclusions: Endoscopic management of cholangitis is as effective as surgical or radiological methods for managing bacterial cholangitis, a potentially fatal syndrome, but ERCP and ES have been shown to be safer. Endoscopy is the preferred index technique both for establishing a definitive diagnosis and providing therapy.

Laparoscopic surgery is proven and efficacious for cholelithiasis, appendicitis, reflux esophagitis, and perforated ulcers. Future reports should be forthright and include cost of equipment, operating room time, and length of surgery so that meaningful analyses and comparisons to traditional surgery can be performed. Laparoscopic surgery is a developing field that will grow in spurts and not without pain or risk. As we sort out objectivity and follow-up data, we will discern fact from fantasy. The influence of industry on this field has been enormous and at odds with what current health administrators will reimburse for procedures. Laparoscopic surgery is not the emperor's new clothes; it has substance and fabric. Operations, like layers of vestments, will be added to and will adorn the surgical mannequin, adding only luster and finery.

Sixty-five patients with symptomatic pancreas divisum were treated by endostents, surgery, or observation. In 35 patients, endoscopic stenting either alone (20) or followed by surgery (15) was the primary therapy. Of 30 patients not stented, 10 underwent elective surgery and 20 were followed. Treatment was based on symptoms and biochemical and radiologic tests. The results of surgical decompression correlated favorably with endoscopic drainage. In untreated patients, the natural history of pancreas divisum was benign. Surgery is safe and effective in symptomatic patients, although multiple operations may be required for recurrent symptoms or progressive disease.

The bone mineral density of 22 random, fresh proximal human femora was estimated by roentgenography using the Singh index (SI) and measured using a regional bone mineral density computed tomographic protocol. Uniaxial compression was used to produce an impacted subcapital fracture. The femoral heads then were isolated and mounted on a sliding screw plate compression device and loaded to failure in a push-out or hip-screw penetration mode. Wide intraobserver variation, poor reproducibility, and poor prediction of the experimental fracture properties of the proximal femur were noted for SI values. Regional bone mineral density provided a reliable estimate of both the gross fracture loads and hip-screw penetration loads. In addition, there was a high correlation between trabecular density and the experimental fracture properties of the proximal femur. Therefore, The validity of the SI as an indicator of the mechanical properties of the proximal femur should be reconsidered.

The first case of a villous lesion of the colon removed by laparoscopic-guided surgery is reported. Injection of methylene blue into the lesion facilitated its access and exposure via the laparoscope. A very small skin incision allowed delivery onto the abdominal wall for resection and anastomoses.

Ninety consecutive patients over a 6-month period with acute (31 patients) or chronic (59 patients) cholecystitis underwent a laparoscopic cholecystectomy on an ambulatory (49 patients), one-night (33 patients), or two-night (5 patients) basis. Three patients required open procedures for 1) perforated duodenal ulcer at 48 h, postoperatively, 2) a cholecystoduodenal fistula, and 3) Mirizzis syndrome with erosion of the common duct. The procedure is safe, efficacious, and should be offered to patients with acute and chronic biliary disease.

Of 11 patients with gallstone pancreatitis, 10 underwent preoperative ERCP. Calculi were removed from the common duct in two patients. All patients underwent laparoscopic cholecystectomy, with normal rapid convalescence. The eleventh patient is recovering from pancreatitis with the bile duct accessed percutaneously. A combined endoscopic and laparoscopic approach to gallstone pancreatitis is safe and was associated with minimal risk in this small series.

Between 1940 and 1978, 150 major pancreatic resections--92 pancreatoduodenal resections (PDRs) and 58 total pancreatectomies (TPs)--were performed for benign and malignant disease. The majority of resections were for pancreatic cancer (70 patients) and ampullary cancer (40 patients). The overall operative mortality rate for PDR was 14%; it was 26% for TP. After resection for adenocarcinoma of the head of the pancreas, the operative mortality rate was 28% for TP and 15% for PDR. The number of 5-year survivors after resection for cancer of the head of the pancreas was four (5.7%). Three survived after PDR and one after TP. Of the 42 adenocarcinomas resected by TP, one of the patients had multicentric cancer and two others had carcinoma in situ. TP appears to have no advantage over PDR for cancers of the head of the pancreas from a theoretical or practical standpoint.

The presenting features of periampullary cancer have been reviewed. Unless the neoplasm is discovered as an incidental finding at surgery, diagnosis is not made until the onset of symptoms (pain, jaundice, weight loss), which is not early, even though these tumors are close to the bile duct or ampulla of Vater. Individual philosophies aside, the prognosis for ampullary, duodenal, or distal bile duct tumors reflects the grade and stage of tumor as much as the operation done. Pancreatoduodenal resection, standard or modified, should be done with an attempt to cure and not to palliate. Statistics that show superior results after resection compared with palliative procedures reflect earlier stages lesions, healthier patients, and, most importantly, patient selection.

On the basis of experimental evidence presented earlier a model of local spectral analysis of the image performed by the complex receptive fields of the visual cortex has been proposed. An essential feature of the model is that the generalized piece-wise Fourier transform is performed not over the image luminance function but over the logarithm contrast function resulted from analysis of the image by the round receptive fields of the preceding levels. Such an assumption removes a number of experimental objections offered against the hypothesis of two-dimensional Fourier transform in the visual system. The consequences from the piece-wise expansion in a series of basic functions have been considered and among them: the channel frequency characteristics which can have more than one maximum; the possibility of describing the image by a limited number of channels with overlapping frequency characteristics; the existence of mechanisms for estimation of phase shift between frequencies.

Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.

An unusual case of systemic mastocytosis with splenomegaly, portal hypertension, and bleeding esophageal varices is presented. Arteriograms and liver biopsy suggested the mechanism of the portal hypertension was due to increased blood flow in the splenic vein, although splenic arteriovenous shunting secondary to histamine release and increased intrahepatic resistance secondary to mast cell infiltration might have played a role. The portal hypertension was relieved by splenectomy.

A 19-year-old man had an abdominal mass and swelling of the left thigh. The presumptive diagnosis was lymphoma. On exploration the mass proved to be a thrombosed multiloculated "cavernous transformation" of a venous structure, presumably the inferior vena cava, which on postoperative cavogram was shown to be otherwise absent. The venous system of the left lower extremity showed phlebographic evidence of old thrombosis, but that of the right lower extremity was normal. The patient did well without further treatment, despite some residual swelling of the left thigh. To our knowledge, this precise combination of inferior vena cava anomalies has not been encountered before; certainly not presenting as a mass.

The unresolved issue of the optimal treatment of portal hypertension attests to the disappointments in present treatment. In reality, the disappointments are a result of progressive liver disease, which is not helped and probably deteriorates more rapidly after shunting operations. This dissatisfaction has led some to abandon shunts and to accept a higher incidence or potential for recurrent bleeding after nonshunting operations. The long-term results of splenic artery ligation and perhaps embolization are awaited with interest. Until then, as Conn has said, "We must learn to select better who should be shunted or to shunt better those we select".

Between 1940 and 1978, 179 patients underwent pancreatic resection (64 total, 102 Whipple, 13 distal) at the Presbyterian Hospital, predominantly for carcinoma of the pancreas and periampullary area. With respect to operative morbidity and mortality and survival, these patients have been compared with 141 patients subjected to pancreatic biopsy only, and with 172 by-passed for palliation. Likewise, total pancreatectomy has been compared to pancreaticoduodenectomy (Whipple) in terms of safety and efficacy. The overall major postoperative complication rate for pancreatic resection was 36%, in contrast with 13.5% for biopsy only and 16.8% for by-pass. Of the resected cases with major complications postoperatively, roughly half died, a mortality of 17.9%. Patients who underwent Whipple resections fared significantly better than did those having total pancreatectomies; the postoperative mortality following 102 Whipples was 14.7%, as compared with 23.4% for total pancreatectomies. Intra-abdominal sepsis accounted for most of the postoperative deaths; nine pancreatic and four biliary leaks or fistulae followed Whipple resections. The later complications were of interest; 18 patients undergoing biliary-en-teric by-pass procedures later developed gastroduodenal obstruction, 15 of whom required reoperation, and in 18 survivors of pancreatic resection, upper gastrointestinal hemorrhage (mostly from marginal ulcers) developed, necessitating surgery in seven. Brittle diabetes was a problem in nine patients following pancreatectomy. Survival rates were discouraging in all categories. For ductal carcinoma of the pancreas, median survival for biopsy only was two months, for by-pass six months, for total pancreatectomy nine months, and for Whipple resection 14 months. There were three five-year survivors following resection, a rate of 4.5%. Five-year survival rates following resection for ampullary, common duct, duodenal, and islet cell cancer were 27.8, 33.3, 27.3, and 37.5%, respectively. It is concluded that survival after resection for ductal pancreatic cancer is so rare as to be considered more a biologic aberration than a result of radical surgery. Despite theoretical advantages of total pancreatectomy over Whipple resections, our experience would suggest that the latter can be carried out with lower morbidity and mortality, and with equal chance for cure. Resection for pancreatic cancer should not be abandoned, but rather undertaken with greater selectivity. Operative morbidity and mortality can probably be improved additionally by preoperative transhepatic biliary decompression, and later complications reduced by including vagotomy with gastric resection at the time of pancreatectomy and by performing prophylactic gastroenterostomies in conjunction with by-pass procedures.

Pancreatic injury is an unusual but serious complication of abdominal trauma. A high index of suspicion is required, as results of routine laboratory tests and physical examination can be misleading. Complications following injury to the body and tail may be particularly indolent in their presentation. Endoscopic retrograde pancreatography allows accurate localization of the site of pancreatic duct disruption and facilitates appropriate surgical management.

Several procedures have been developed to obtain decompression of protal hypertension for bleeding esophageal varices. In recent years, the distal splenorenal shunt has become popular becuase it causes less encephalopathy than the standard portacaval or mesocaval shunts. A criticism of the distal splenorenal shunt has been the technical difficulty of dissecting the splenic vein and obtaining adequate exposure. We have facilitated some of these difficulties by exposing a retroperitoneal approach and by the use of a Smith ring retractor.

Twelve patients with intra-abdominal or mediastinal abscesses were treated by percutaneous drainage. Three abscesses were subphrenic, three were adjacent to enteric leaks, two were intrahepatic, two were pancreatic pseudocysts, one was a pancreatic abscess extending to the lesser sac, and one was an infected adrenal hematoma. All 12 lesions were entered percutaneously using fluoroscopic guidance without traumatizing the adjacent normal tissue. Localization was frequently aided by computed tomography. Various catheters were positioned using basic angiographic techniques. Following drainage all patients had a favorable clinical response. Seven of the 12 patients required no surgical management. Careful radiologic follow-up and frequent changing of catheters was necessary in six of the patients. Two patients benefited from the addition of auxiliary drains. Five of the 12 patients were electively operated upon because of incomplete drainage of the abscess cavity. Causes of failure were: persistent anastomotic leak (two patients), sequestered, loculated extension of abscess cavity (two patients), or necrotic, viscous hepatic tissue requiring removal at laparotomy (one patient).